1. Hospital Acquired Infections (HAI)
DR. MAZIN BARRY, MD, FRCPC, FACP, DTM&H
Infectious Disease Consultant
Assistant Professor of Medicine

2. Objectives Know different types of HAI and how to prevent them
Highlight the crucial importance of Hand Hygiene
Understand different types of Isolation Precautions and how to comply with them

3. Hospital Acquired Infections (HAI)
Between 5% and 10% of patients admitted to hospitals acquire one or more HAI
Causes more serious illness
Prolong hospital stay
Long-term disability
High personal burden on patients and their families
High additional financial burden
Deaths

4. Estimated rates of HAI worldwide
In the developed world: 5–10% of patients acquire one or more infections
In developing countries :
HAI can exceed 25%
In intensive care units:
HAI affects about 30% of patients and the attributable mortality may reach 44%

5. Source of infection HAIs are caused by infectious agents from:
1] Endogenous sources such as the skin, nose, mouth, GI tract, or vagina that are normally inhabited by microorganisms (normal flora)
2] Exogenous sources external to the patient such as health care workers (HCW), visitors, patient care equipment, medical devices, or the health care environment

6. Types of HAI Catheter-Associated Urinary Tract Infections (CAUTI)
Catheter-Associated Bloodstream Infections (CLABSI)
Ventilator-Associated Pneumonia
(VAP)
Surgical site infections
(SSI)

7. Catheter-Associated Urinary Tract Infections (CAUTI)
Indwelling urinary catheter
Urinary invasive procedures
Risk Factors:
Advanced age
Severe underlying disease
Urolithiasis
Pregnancy DM

8. CAUTI Most common type of HAI: > 30%
Estimated > 500,000 of hospital UTIs annually
Increased morbidity & mortality
Estimated 13,000 attributable deaths annually
Leading cause of secondary blood stream infection with ~10% mortality
Excess length of stay: 2-4 days

9. Indwelling Urinary Catheters
15-25% of hospitalized patients
Often placed for inappropriate indications
Physicians frequently unaware:
> 50% did not monitor which patients catheterized
75% did not monitor duration and/or discontinuation

10. Pathogenesis of CAUTI Source of microorganisms:
Endogenous (meatal, rectal, or vaginal )
Exogenous, usually via contaminated hands of HCW during catheter insertion or manipulation of the collecting system

11. Pathogenesis of CAUTI
Formation of biofilms by urinary pathogens is common on the surfaces of catheters and collecting systems
Bacteria within biofilms are resistant to antimicrobials and host defenses
Must remove catheter for cure

12. CAUTI Symptomatic UTI must meet at least 1 of the following criteria
Fever (380 C or above), urgency, frequency, dysuria, or suprapubic tenderness
Positive urine culture, that is more than 105 CFU per ml, with no more than 2 species of microorganisms
A positive culture of a urinary catheter tip is not an acceptable laboratory test to diagnose UTI

13. Prevention: CAUTI Bundle
Insert catheters only for appropriate indications
Leave catheters in place only as long as needed
Ensure that only properly trained persons insert and maintain catheters
Insert catheters using aseptic technique and sterile equipment (acute care setting)
Following aseptic insertion, maintain a closed drainage system
Maintain unobstructed urine flow
Daily revision of need of catheterization
Hand hygiene

14. Prevention: CAUTI Bundle
Minimize use in all patients, particularly those at higher risk of CAUTI and mortality :
Women, elderly, impaired immunity
Avoid its use for management of incontinence
Use catheters in operative patients only as necessary
Remove catheters ASAP postoperatively, preferably within 24 hours, unless there are appropriate indications for continued use

15. Surgical Site Infection (SSI)
Inadequate antibiotic prophylaxis
Incorrect surgical skin preparation
Inappropriate wound care
Risk Factors:
Surgery duration
Type of surgery: clean, clean-contaminated, contaminated, dirty
Type of wound
Improper surgical aseptic preparation
Poor glucose control
malnutrition
Immunodeficiency
hypothermia
Lack of training and supervision

16. SURGICAL WOUND CLASSIFICATIONS
I. Clean:
Uninfected, no inflammation
Resp, GI, GU tracts not entered
Closed primarily
Examples: Ex lap, mastectomy, neck dissection, thyroid, vascular, hernia, splenectomy
II. Clean-contaminated:
Resp, GI, GU tracts entered, controlled
No unusual contamination
Examples: Chole, SBR, Whipple, liver txp, gastric surgery, bronch, colon surgery

17. SURGICAL WOUND CLASSIFICATIONS
III: Contaminated:
Open, fresh, accidental wounds
Major break in sterile technique
Gross Spillage from GI tract
Acute nonpurulent inflammation
Examples: Inflamed appendix, bile spillage in chole, diverticulitis, Rectal surgery, penetrating wounds
IV: Dirty:
Old traumatic wounds, devitalized tissue
Existing infection or perforation
Organisms present BEFORE procedure
Examples: Abscess I&D, perforated bowel, peritonitis, wound debridement, positive cultures pre-op

18. SSI Burden 17% of all HAI; second to UTI
2%-5% of patients undergoing inpatient surgery
Mortality
3 % mortality
2-11 times higher risk of death
75% of deaths among patients with SSI are directly attributable to SSI
Morbidity
long-term disabilities

19. Superficial SSI
Infection occurs within 30 days after the operative procedure and involves only skin and subcutaneous tissue of the incision
Purulent drainage from the superficial incision
Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision
Often Clinical diagnosis: pain or tenderness, localized swelling, redness, or heat, lack of systemic symptoms (e.g. fever)
A negative culture does not rule it out

20. Deep SSI
Infection occurs within 30 days after the operative procedure if no implant is left in place or within 1 year if implant is in place and the infection appears to be related to the operative procedure
involves deep soft tissues (eg, fascial and muscle layers) of the incision
Clinically may have abscess, fever

21. SSI Pathogenesis Pathogen Sources: Endogenous Patient flora
skin
mucous membranes
GI tract
Seeding from a distant focus of infection

22. SSI Pathogenesis Pathogen Sources: Exogenous
Surgical Personnel (surgeon and team)
Soiled attire
Breaks in aseptic technique
Inadequate hand hygiene
O.R. physical environment and ventilation
Tools, equipment, materials brought to the operative field

23. Organisms Causing SSI Staphylococcus aureus 30.0%
Coagulase-negative staphylococci %
Enterococcus spp %
Escherichia coli %
Pseudomonas aeruginosa %
Enterobacter spp %
Klebsiella pneumoniae %
Candida spp %
Klebsiella oxytoca %
Acinetobacter baumannii %

24. SSI Epidemiology Important Modifiable Risk Factors:
Antimicrobial prophylaxis
Inappropriate choice (procedure specific)
Improper timing (pre-incision dose)
Inadequate dose based on body mass index, procedures >3h
Skin or site preparation ineffective
Colorectal procedures
Inadequate bowel prep/antibiotics
Inadequate wound dressing protocol
Improper glucose control
Colonization with preexisting microorganisms

25. SSI Prevention Strategies
Preoperative Measures:
Administer antimicrobial prophylaxis in accordance with evidence based standards and guidelines
Administer within minutes to incision
1-2hr for vancomycin and fluoroquinolones
Select appropriate agents on basis of
Surgical procedure
Most common SSI pathogens for the procedure
Published recommendations

26. SSI Prevention Strategies
Nasal screen and decolonize only
Staphylococcus aureus carriers undergoing
1) Elective cardiac surgery
2) Orthopaedic surgery
3) Neurosurgery procedures with implants
USING
Pre-operative mupirocin ointment therapy

27. Prevention: SSI Bundle
Shower night before surgery
Antimicrobial prophylaxis should be administered only when indicated
Certain surgeries only
Single pre-operative dose min before incision
Topical antibiotics should not be applied to the surgical site
In clean and clean-contaminated surgery: No additional prophylactic antimicrobial doses should be given even in the presence of a drain
Skin preparation in the O.R. by alcohol-based agent
Good glycemic control during surgery
Normothermia should be maintained throughout surgery
Administration of FIO2 during surgery and after extubation

28. CLABSI Definition: Most common site: femoral central lines
Laboratory-confirmed bloodstream infection by a positive blood culture
Not related to an infection at another site
Develops at least after 48 hours of a central line placement
Most common site: femoral central lines

29. CLABSI Organisms GPC GNB: Candida spp. 12% Other 10% CoNS 35%
 enterococci spp 15%;
Staphylococcus aureus 10%
GNB:
Klebsiella pneumoniae 6%
E.coli 3%
Enterobacter spp. 3%
Pseudomonas aeruginosa 3%
Acinetobacter baumanii 2%
Candida spp. 12%
Other 10%

30. CLABSI Treatment Removal of central line Antimicrobial therapy
Type and duration depends on culture results, type of organism, complicated disease
e.g. of antibiotics used: Vancomycin, cloxacillin, cefazolin, piperacillin/ tazobactam, cefepime, ceftazidime, carbapenems, Aminoglycosides, colistin, daptomycin, echinocandins

31. CLABSI Prevention Bundle
Prevention Guidelines During Insertion:
Hand hygiene before wearing gloves
Strict aseptic technique by maximal sterile barrier precautions including a full-body drape
Use of 2% chlorhexidine skin preparations for disinfecting/ cleaning skin before insertion
Ultrasound guidance by an experienced personnel and reduce the number of attempts. 
Avoid the femoral vein, prefer the subclavian vein
Promptly remove any central line that is no longer required
Replace central lines placed during an emergency (asepsis not assured) as soon as possible or at least within 48 hours
Use a checklist

32. CLABSI Prevention Bundle
Prevention Guidelines During Maintenance:
Disinfect catheter hubs, injection ports, and connections before accessing line
Replace administration sets other than sets used for lipids or blood products every 96 hours
Assess the need for the central line daily

33. VAP
VAP is one of the most common infections acquired by adults and children in intensive care units
Affects critically ill patients
VAP is a cause of significant morbidity and mortality, increased utilization of healthcare resources
The mortality attributable to VAP exceed 15%

34. Pathogenesis of and risk factors for VAP
The 3 common mechanisms:
Aspiration of secretions
Colonization of the aerodigestive tract
Use of contaminated equipment

35. Prevention: VAP Bundle
1-Prevent aspiration of secretions
2-Reduce duration of ventilation
3-Reduce colonization of airway and digestive tract
4-Prevent exposure to contaminated equipment

36. VAP Bundle Prevent Aspiration of Secretions
Maintain elevation of head of bed (HOB) degrees
Avoid gastric over-distention
Avoid unplanned extubation and re-intubation
Use cuffed endotracheal tubewith in-line or subglottic suctioning
Encourage early mobilization of patients with physical/occupational therapy

37. VAP Bundle Reduce Duration of Ventilation Conduct “sedation vacations”
Assess readiness to wean from vent daily
Conduct spontaneous breathing trials

38. VAP Bundle Reduce Colonization of Airway and Digestive Tract
Use cuffed Endotracheal Tube with inline or subglottic suctioning
Minimizes secretions above cuff; prevents contamination of lower airway
Avoid acid suppressive therapy for patients not at high risk for stress ulcer or stress gastritis
Increases colonization of the digestive tract

39. Most frequent sites of infection and their risk factors
URINARY TRACT INFECTIONS
Urinary catheter
Urinary invasive procedures
Advanced age
Severe underlying disease
Urolitiasis
Pregnancy
Diabetes
34%
13%
LOWER RESPIRATORY TRACT INFECTIONS
Mechanical ventilation
Aspiration
Nasogastric tube
Central nervous system depressants
Antibiotics and anti-acids
Prolonged health-care facilities stay
Malnutrition
Advanced age
Surgery
Immunodeficiency
LACK OF HAND HYGIENE
Most common sites of health care- associated infection and the risk factors underlying the occurrence of infections
SURGICAL SITE INFECTIONS
Inadequate antibiotic prophylaxis
Incorrect surgical skin preparation
Inappropriate wound care
Surgical intervention duration
Type of wound
Poor surgical asepsis
Diabetes
Nutritional state
Immunodeficiency
Lack of training and supervision
BLOOD INFECTIONS
Vascular catheter
Neonatal age
Critical care Severe underlying disease
Neutropenia
Immunodeficiency
New invasive technologies
Lack of training and supervision
17%
14%

40. Prevention of HAI
Validated and standardized prevention strategies have been shown to reduce HAI
At least 50% HAI could be prevented
Most solutions are simple and not resource-demanding and can be implemented with ease by all HCW
Hand hygiene
Bundles
Compliance with isolation precautions
Annual influenza vaccination
Annual TB screening: TST, IGRA
UpToDate with vaccinations: HBV Ab titre above 10, MMRV, Td

41. Hand transmission
Hands are the most common vehicle to transmit healthcare associated pathogens
Transmission of microbiological organisms from one patient to another via HCW hands

42. Why should you clean your hands
Any HCW involved in health care needs to be concerned about hand hygiene
Other HC workers (e.g. your colleagues and seniors) hand hygiene concerns you as well
You must perform hand hygiene to :
- protect the patient against harmful microbes in your hands or present on your skin
- protect yourself and the healthcare environment from harmful microbes

43. Bacteria isolated everywhere (e.g. VRE)

44. Five moments of hand hygiene

45. 5 Moments of Hand hygiene

46. How to clean your hands
Handrubbing with alcohol-based handrub is the preferred routine method of hand hygiene if hands are not visibly soiled
Handwashing with soap and water – essential when hands are visibly dirty or visibly soiled (following exposure to body fluids)

48. Hand hygiene and glove use
The use of gloves does not replace the need to clean the hands
Remove gloves to perform Hand hygiene, when an indication occurs while wearing gloves
Wear gloves only when indicated, otherwise they become a major risk for germ transmission

49. Types of Isolation Precautions
Standard precautions
Transmission-based precautions
Contact precautions
Airborne precautions
Droplet precautions

50. TRANSMISSION-BASED PRECAUTIONS - Contact Precautions
Infections spread by direct or indirect contact with patients or patient-care environment –C. difficle, MRSA, VRE, ESBL, CRE and MDR GNR
Limit patient movement
Private/SINGLE room or cohort with patients with same infection
Wear disposable gown and gloves when entering the patient room
Remove and discard used gown and gloves inside the patient room
Wash hands immediately after leaving the patient room
Use dedicated equipment if possible (e.g., stethoscope)
Consists of standard precautions (see previous frames) plus precautions for direct and indirect contact
Infections spread by direct or indirect contact with patients or patient-care environment – shigellosis, C. difficle, MRSA
Limit patient movement
Private room or room shared with patients with same infection status
Wear disposable gown and gloves when entering the patient room
Remove and discard used disposable gown and gloves inside the patient room
Wash hands immediately after leaving the patient room
Clean patient room daily using a hospital disinfectant, with attention to frequently touched surfaces (bed rails, bedside tables, lavatory surfaces, blood pressure cuff, equipment surfaces)
Use dedicated equipment if possible (e.g., stethoscope)

51. Contact precautions signs

52. Droplet Precautions
Reduce the risk of transmission by large particle droplets (larger than 5 m in size).
Requires close contact between the source person and the recipient
Droplets usually travel 3 feet or less
E.g., influenza, MERS-CoV, other respiratory viruses, rubella, parvovirus B19, mumps, H. influenzae, and N. meningitidis
Consists of standard precautions plus specifics for droplet precautions
Ues to reduce the risk of transmission of microorganisms transmitted by large particle droplets (larger than 5 m in size).
Droplet transmission requires close contact between the source person and the recipient because droplets do not remain suspended in the air.
Droplets usually travel 3 feet or less within the air and thus special air handling is not required.
Droplet transmission involves contact of the conjunctiva of the eyes or the mucous membranes of the nose or mouth of a person with the microorganism generated from the infected source person during coughing, sneezing or talking, or during the performance of procedures such as suctioning and bronchoscopy.

53. Droplet Precautions cont.
A private/single room or
Cohort with patient with active infection with same microorganism
Use a mask when entering the room especially within 3 feet of patient
Limit movement and transport of the patient. Use a mask on the patient if they need to be moved and follow respiratory hygiene/cough etiquette
Place the patient in a private/single room or if not available
Cohort with patient with active infection with same microorganism
Use of respiratory protection such as a mask when entering the room recommended and definitely if within 3 feet of patient
Limit movement and transport of the patient. Use a mask on the patient if they need to be moved and follow repiratory hygiene/cough etiquette
Keep patient at least 3 feet apart between infected patient and visitors
Room door may remain open

54. Droplet precautions signs

55. Airborne Precautions
Tuberculosis, measles, varicella, MERS-CoV (severe)
Place the patient in an airborne infection isolation room (AIIR)
Negative Pressure should be monitored with visible indicator
Use of respiratory protection (e.g., fit tested N95 respirator) or powered air-purifying respirator (PAPR) when entering the room
Limit movement and transport of the patient. Use a mask on the patient if they need to be moved
Keep patient room door closed, do not open anteroom door till other door closed

56. Airborne precautions signs